When her artificial right hip became infected with the superbug MRSA in late 2009, Dr. Dale Mitchum, a general surgeon, drained, cleaned and closed the infected area. But when the infection returned in early 2010, Mitchum knew Duck needed another hip replacement surgery, which he couldnt perform. He tried to find an orthopedic surgeon who would operate. More than a year later, hes still trying.

I cannot find a living soul that will touch her, he said recently. And Ive tried everywhere, from Tallahassee to Pensacola.

Doctors in several states outside Florida also have refused to operate on Duck, whos covered by Medicaid, the state-federal health insurance program for poor people and those with disabilities. Because of the programs history of low payments, fewer than half of U.S. doctors and other health care professionals accept Medicaid patients, according to a recent study.

For those that do, getting an appointment sometimes can take months because of the high demand, particularly among specialists.

The problem is worse in rural areas such as Bonifay, in the Florida Panhandle. While 20 percent of Americans live in less-populated parts of the country, only 10 percent of U.S. doctors practice there. Thats why 77 percent of the nations 2,000-plus rural counties are designated as health professional shortage areas, according to the National Conference of State Legislatures.

Nationwide, the lack of doctors is a growing problem that will only worsen as some 27 million people get health coverage by 2016 as part of the Patient Protection and Affordable Care Act. The Association of American Medical Colleges projects a shortage of 29,800 primary care doctors and 33,000 specialty doctors in 2015 alone.

If left unaddressed, the shortage of doctors and their rejection of Medicaid patients could severely hamper the health care overhaul next year, when 5 million to 8 million Americans will gain Medicaid coverage under the law.

While the health care law also provides for steeply increasing Medicaid fees to doctors this year and next year, some physicians worry that the payments would drop again in 2015.

The new law allows state Medicaid programs to cover non-elderly adults who earn up to 138 percent of the federal poverty level. Thats nearly $16,000 for an individual in 2013 or about $32,500 for a family of four.

As of Monday, 26 states and the District of Columbia are slated to participate in the Medicaid expansion, while New York is leaning that way, according to the Advisory Board Company, a global research and consulting firm.

But as Ducks experience shows, a Medicaid insurance card doesnt guarantee care if there arent enough physicians to treat the new enrollees or wide swaths of doctors simply wont see them.

Despite a regimen of antibiotics, Duck, a former hairdresser, said her hip was getting worse. A bone has grown around a metal rod in the replacement hip and she fears that the infection could make the damage irreversible if surgery is delayed much longer.

Medicaid doesnt pay enough, so they just dont want to fool with me, Duck said. They just want me to be quiet and sit back and just let my leg rot off. Well, thats hard to do when Im 44 years old and Ive got two grandkids. Ive still got a little bit of life left in me.

Of more than 1 million physicians, therapists and counselors nationwide, only 43 percent accept Medicaid, according to a new study by HealthPocket, a technology firm that compares and ranks health plans.

The situation varies by city. The study found that only 31 percent of caregivers accept Medicaid patients in Washington and Detroit, 36 percent in San Francisco, 42 percent in Philadelphia and San Diego, and 47 percent in Seattle.

If the current Medicaid acceptance rates hold true for 2014, timely access to care for those relying on Medicaid is likely to become more difficult as enrollees compete for an already inadequate pool of doctors, said Kev Coleman, the head of research and data at HealthPocket.

The lean physician workforce has prompted some states to try to expand the types of primary care provided by nurse practitioners, physician assistants and other non-physician medical personnel. But the HealthPocket study found that only 20 percent of physician assistants and nurse practitioners nationally accept Medicaid, less than half the rate of doctors and other providers.

Last year, Medicaid paid physicians just two-thirds of what they received from Medicare, the federal health insurance program for people 65 and older. Medicaids fees for primary care averaged 41 percent less than Medicares, according to the Kaiser Family Foundation, a nonpartisan health care philanthropic organization.

To retain the doctors who take Medicaid patients and to recruit new ones, the health care law hikes Medicaid primary care payments to the same level as Medicares in 2013 and 2014. The increase varies by state, but it averages 73 percent nationwide, according to Kaiser.Doctors in a dozen states will see average fee increases of more than 50 percent, while those in Florida, California, New York, New Jersey, Michigan and Rhode Island will see their Medicaid payments more than double, according to the Kaiser study.

The increases were supposed to begin this year, but the process was delayed. The U.S. Department of Health and Human Services is now providing technical assistance to states to expedite the payments, but the going is slow.

I dont know of any state where the money is actually flowing to physicians yet, said Andrea Maresca, the director of federal policy at the National Association of Medicaid Directors. Once implemented, the Medicaid pay hikes will be retroactive to Jan. 1. Maresca said the delays hadnt sparked much outrage so far.

Were not hearing a deluge of concern from states that because this money isnt flowing, providers are dropping Medicaid patients, she said.

But doctors such as Leisa Bailey, an obstetrician-gynecologist in rural Bonifay, said the two-year pay hike could backfire if Congress didnt reinstate it in 2015. Failure to do so might cause doctors to turn away millions of Medicaid patients because treating them once again would be a money loser.

Youd be asking the physicians, basically, to kick those patients out. It is the craziest thing I ever heard in my life, Dr. Bailey said.

Bailey said shed continue to see pregnant Medicaid patients, but because Congress might kill the pay increase after two years, she wont open up her practice to all Medicaid recipients. If she did, she fears the wave of new Medicaid patients would lead her Medicare patients and those with private insurance to seek care elsewhere.

Dr. Adit Ginde, of the University of Colorado School of Medicine in Aurora, has studied obstacles to patient care for Medicaid recipients. He said it was unlikely that doctors would drop current Medicaid patients if the pay increase werent renewed, but they might stop taking new ones.

Once theyre in an established practice, then typically they can stay within that practice, Ginde said. But its much more difficult to initiate a new relationship.

Just ask Sandra Duck. As she looked for a surgeon to operate on her infected hip, Duck said she was growing weary of the struggle. The infection is spreading down her leg, the antibiotics are becoming less effective and she needs a pillow just to sit.

Johns Hopkins Hospital in Baltimore recently took an interest in her case, and Duck was optimistic about her chances.

I feel like theyre the only people I trust, she said after hearing the news. I just believe in them. I dont know why, but Ive got a good feeling about them.

But Hopkins turned her down as well. Once again, Dr. Mitchum said, Medicaid was the problem. The hospital declined to comment on the case, citing privacy laws.

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